Results from STITCH Trial Demonstrate a Simplified, Step-Care Process is More Effective than Guidelines-Based Practice in Hypertension Treatment

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November 4, 2007 By Lauren Ciaglo [1]

Orlando, FL: Results from the Simplified Therapeutic Intervention to Control Hypertension (STITCH) Trial demonstrate that a simplified, step-care process for treating hypertension is more effective in helping people reduce their blood pressure compared with guidelines-based practice. The study was presented at the American Heart Association 2007 Scientific Sessions by Dr. Ross Feldman on behalf of the STITCH investigators.

Nonadherence of patients to their prescribed treatment regimen is a major problem. Approximately 50% of patients will discontinue their use of drugs, including antihypertensives, within 1 year. An additional 35% discontinue treatment within 2 years. Some common causes for patient noncompliance include complex dosing regimens and “therapeutic turbulence” (decreased adherence to treatment as a result of switching drugs). There are also factors within the health care system that create barriers for optimal patient management, some of which include: failure to meet treatment targets, inadequate patient counseling and follow-up, and increasingly complex treatment alogorithms.

This study included 2,104 patients with hypertension at 45 family practices throughout southwestern Ontartio, Canada. The family practices were randomly selected to implement either the simplified step-care algorithim (STITCH-care, 18 practices) or guidelines-based care for managing hypertension (27 practices). The STITCH strategy consisted of 4 steps: (1) Start ½ tab low dose combination (either ACE-inhibitor/diuretic or ARB/diuretic), (2) Increase combination dose, (3) Add a calcium channel blocker, and (4) Add an α-blocker, β-blocker, or spironolactone.

The primary endpoint of proportion of practice at blood pressure target was 64.8% in the STITCH-care group (95% CI: 57.6%, 72.0%) compared with 52.7% percent in the guideline-care group (95% CI: 45.3%, 60.1%; p=0.03). Additionally, systolic blood pressure was significantly reduced by 23 mmHg in the STITCH-care arm compared with 18 mmHg in the guideline-care arm. Diastolic blood pressure was significantly lower in the STITCH-care arm as well, decreasing by 10 mmHg compared with 8 mmHg in the guideline-care arm.

The STITCH study demonstrated that among patients with hypertension, a more simplified step-care protocol resulted in greater use of fixed-dose antihypertensive combinations. The STITCH strategy is both implementable and well accepted by physicians. Implementation of the STITCH strategy in the setting of family practice resulted in better blood pressure control.